Download Trauma In The Pregnant Patient: An Evidence

Trauma In The Pregnant
Patient: An Evidence-Based
Approach To Management
April 2013
Volume 15, Number 4
Authors
Kurt A. Smith, MD
Assistant Professor of Emergency Medicine, Vanderbilt University
Medical Center, Nashville, TN
Suzanne Bryce, MD
Department of Emergency Medicine, Vanderbilt University Medical
Center, Nashville, TN
Abstract
The management of acute trauma in the pregnant patient relies
on a thorough understanding of the underlying physiology of
pregnancy. This issue reviews the evidence regarding important
considerations in pregnant trauma patients, including the primary
and secondary survey as well as the possibility for Rh exposure,
placental abruption, uterine rupture, and the need for a prompt
perimortem cesarean section in the moribund patient. Because ionizing radiation is always a concern in pregnancy, the circumstances
where testing provides benefits that outweigh risks to the fetus are
discussed. Emergency clinicians are encouraged to advocate for
trauma prevention, including proper safety restraints for motor
vehicles and screening for domestic violence, as these measures
have been shown to be effective in reducing morbidity and mortality in this population. Recommendations for monitoring, admission, discharge, and follow-up are also noted.
Peer Reviewers
Kamal Gursahani, MD, MBA
Assistant Professor of Emergency Medicine, Saint Louis University
School of Medicine, St. Louis, MO
Carolyn K. Synovitz, MD, MPH, FACEP
Clinical Associate Professor, Adjunct, Department of Emergency
Medicine, University of Oklahoma School of Community Medicine,
Tulsa, OK; Attending Physician, Jackson County Memorial Hospital,
Altus, OK
CME Objectives
Upon completion of this article, you should be able to:
1.
2.
3.
4.
Discuss the differences in maternal physiology that may
complicate care of the pregnant trauma patient.
Describe the perinatal catastrophes inherent in obstetric trauma,
including abruption, amniotic fluid embolus, uterine rupture, and
maternal cardiac arrest.
Explain the imaging modalities that are used in assessing the
pregnant trauma patient and their risks and benefits.
Assess the indications for and the timeline of a perimortem
cesarean section as well as the technique used.
Prior to beginning this activity, see the back page for faculty
disclosures and CME accreditation information.
Editor-in-Chief
Nicholas Genes, MD, PhD
Assistant Professor, Department of
Andy Jagoda, MD, FACEP
Emergency Medicine, Mount Sinai
Professor and Chair, Department of
School of Medicine, New York, NY
Emergency Medicine, Mount Sinai
School of Medicine; Medical Director, Michael A. Gibbs, MD, FACEP
Mount Sinai Hospital, New York, NY
Professor and Chair, Department
of Emergency Medicine, Carolinas
Associate Editor
Medical Center, University of North
Kaushal Shah, MD, FACEP
Carolina School of Medicine, Chapel
Associate Professor, Department of
Hill, NC
Emergency Medicine, Mount Sinai
Steven A. Godwin, MD, FACEP
School of Medicine, New York, NY
Professor and Chair, Department
of Emergency Medicine, Assistant
Editorial Board
Dean, Simulation Education,
William J. Brady, MD
University of Florida COMProfessor of Emergency Medicine
Jacksonville, Jacksonville, FL
and Medicine, Chair, Medical
Gregory L. Henry, MD, FACEP
Emergency Response Committee,
CEO, Medical Practice Risk
Medical Director, Emergency
Assessment, Inc.; Clinical Professor
Management, University of Virginia
of Emergency Medicine, University of
Medical Center, Charlottesville, VA
Michigan, Ann Arbor, MI
Peter DeBlieux, MD John M. Howell, MD, FACEP
Professor of Clinical Medicine,
Clinical Professor of Emergency
Interim Public Hospital Director
Medicine, George Washington
of Emergency Medicine Services,
University, Washington, DC; Director
Emergency Medicine Director of
of Academic Affairs, Best Practices,
Faculty and Resident Development,
Inc, Inova Fairfax Hospital, Falls
Louisiana State University Health
Church, VA
Science Center, New Orleans, LA
Keith A. Marill, MD
Assistant Professor, Harvard Medical
School; Emergency Department
Attending Physician, Massachusetts
General Hospital, Boston, MA
International Airport, Nashville, TN
Stephen H. Thomas, MD, MPH
George Kaiser Family Foundation
Professor & Chair, Department of
Emergency Medicine, University of
Oklahoma School of Community
Medicine, Tulsa, OK
Charles V. Pollack, Jr., MA, MD,
FACEP
Chairman, Department of Emergency
Jenny Walker, MD, MPH, MSW
Medicine, Pennsylvania Hospital,
Assistant Professor, Departments of
University of Pennsylvania Health
Preventive Medicine, Pediatrics, and
System, Philadelphia, PA
Medicine Course Director, Mount
Michael S. Radeos, MD, MPH
Sinai Medical Center, New York, NY
Assistant Professor of Emergency
Ron M. Walls, MD
Medicine, Weill Medical College
Professor and Chair, Department of
of Cornell University, New York;
Emergency Medicine, Brigham and
Research Director, Department of
Women’s Hospital, Harvard Medical
Emergency Medicine, New York
School, Boston, MA
Hospital Queens, Flushing, New York
Robert L. Rogers, MD, FACEP,
FAAEM, FACP
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Scott Weingart, MD, FACEP
Associate Professor of Emergency
Medicine, Mount Sinai School of
Medicine; Director of Emergency
Critical Care, Elmhurst Hospital
Center, New York, NY
Alfred Sacchetti, MD, FACEP
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Senior Research Editors
James Damilini, PharmD, BCPS
Clinical Pharmacist, Emergency
Room, St. Joseph’s Hospital and
Medical Center, Phoenix, AZ
Shkelzen Hoxhaj, MD, MPH, MBA
Francis M. Fesmire, MD, FACEP
Chief of Emergency Medicine, Baylor Scott Silvers, MD, FACEP
Professor and Director of Clinical
Joseph D. Toscano, MD
Chair, Department of Emergency
College of Medicine, Houston, TX
Research, Department of Emergency
Emergency Physician, Department
Medicine, Mayo Clinic, Jacksonville, FL
Medicine, UT College of Medicine,
Eric Legome, MD
of Emergency Medicine, San Ramon
Chattanooga; Director of Chest Pain
Chief of Emergency Medicine,
Corey M. Slovis, MD, FACP, FACEP
Regional Medical Center, San
Center, Erlanger Medical Center,
King’s County Hospital; Professor of
Professor and Chair, Department
Ramon, CA
Chattanooga, TN
Clinical Emergency Medicine, SUNY
of Emergency Medicine, Vanderbilt
Downstate College of Medicine,
University Medical Center; Medical
Brooklyn, NY
Director, Nashville Fire Department and
Research Editor
Michael Guthrie, MD
Emergency Medicine Residency,
Mount Sinai School of Medicine,
New York, NY
International Editors
Peter Cameron, MD
Academic Director, The Alfred
Emergency and Trauma Centre,
Monash University, Melbourne,
Australia
Giorgio Carbone, MD
Chief, Department of Emergency
Medicine Ospedale Gradenigo,
Torino, Italy
Amin Antoine Kazzi, MD, FAAEM
Associate Professor and Vice Chair,
Department of Emergency Medicine,
University of California, Irvine;
American University, Beirut, Lebanon
Hugo Peralta, MD
Chair of Emergency Services,
Hospital Italiano, Buenos Aires,
Argentina
Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency
Medicine, King Chulalongkorn
Memorial Hospital, Thai Red Cross,
Thailand; Faculty of Medicine,
Chulalongkorn University, Thailand
Suzanne Peeters, MD
Emergency Medicine Residency
Director, Haga Hospital, The Hague,
The Netherlands
Case Presentations
All shifts have a theme. Unfortunately, as you start your
day in the ED, you realize that today’s theme is not your
favorite. In the first hour of your shift, a 30-week pregnant patient arrives from a relatively minor motor vehicle
collision. She was ambulatory at the scene despite presenting with lower extremity pain with an obviously deformed
ankle and a sore neck. Otherwise, she looks fine, and she
reassures you that she isn’t having any abdominal pain.
She is insistent that she does not want any radiation, that
she does not want to be observed, and that she would like
to be discharged. Although rapid discharge seems attractive, you are concerned about the potential risk to the
fetus and wonder what the best practice recommendations
are for managing your 2 patients . . .
As you mull over how to best care for both this mother
and baby, a second pregnant patient arrives. She is 24
weeks pregnant and fell while jogging. She thinks that she
felt a contraction as the nurse was getting her into a gown.
While well-appearing and embarrassed by her clumsiness,
there is something about her that makes you feel uneasy . . .
Brooding that this just isn’t your day, the radio brings
you back to reality as a very distraught paramedic hurriedly relates that they’re about 2 minutes out with another
motor vehicle collision victim who looks sick and is tachycardic, hypotensive, and having agonal respirations. He
relates that the husband is frantically screaming that she’s
due next month to have a baby girl. As your team gears up
for the ensuing disaster about to descend on your trauma
room, you realize that the ambulance is going to arrive
much faster than your obstetrician on call (who is coming
from home). You fully appreciate that the opening moves of
this drama are going to be entirely up to you. . . .
Introduction
Few things in emergency practice evoke more anxiety
than the pregnant trauma patient. The “package deal”
of 2 patients in 1 requires that the emergency clinician simultaneously manage both patients, only 1 of
whom may be able to verbalize complaints. Pregnancy provokes anxiety in the patient (who often is concerned about possible complications to her unborn
child due to trauma) as well as healthcare providers
(who realize that intrauterine complications can be
hidden). Careful attention to differences in maternal
physiology during pregnancy and a broad differential of the possible complications of pregnancy (even
with relatively minor trauma) are requisite to avoid
catastrophe, as the physiology and nature of injuries
can be strikingly different in a pregnant patient. In
this issue of Emergency Medicine Practice, the approach
to the pregnant trauma patient is reviewed; pitfalls
of management are highlighted; and controversies
in testing and imaging are discussed, including issues regarding radiation exposure for the fetus. An
evidence-based approach to clinical decision making
Emergency Medicine Practice © 20132
from the care of minor injuries to the perimortem
cesarean section are presented.
Critical Appraisal Of The Literature
A literature search of current articles from 1946
to present was conducted with Ovid MEDLINE®
and PubMed utilizing the following search terms
coupled with pregnant and pregnancy: trauma, blunt
trauma, penetrating trauma, motor vehicle collision,
orthopedic injury, fracture, perimortem cesarean section,
trauma management, radiation, imaging, ultrasound,
abruption, fetal monitoring, Kleihauer-Betke, Rh immunization, amniotic fluid embolism, uterine rupture, and
carbon monoxide. The resulting 12,000 articles were
limited to those published in the last 20 years, and
they were evaluated for relevance and applicability. The remaining 162 articles were evaluated using
standard evidence-level scales to determine their
weight with regard to current practice. Bibliographies of relevant articles were then used to uncover
further articles pertinent to the topic. The Cochrane
Database of Systematic Reviews was searched using
the terms pregnancy and trauma; the only relevant
review concerned effective treatments for placental
abruption. The Cochrane review authors concluded
that there were no available data from which to
draw any guidelines.1
In assessing the body of literature as a whole, it
is apparent that this is an area of emergency medicine that lacks definitive evidence and well-designed
studies. Pregnant patients are often excluded from
major protocols, and they represent a smaller subset
of trauma patients that is frequently excluded from
outcomes research. Consequently, the literature is
rife with case studies and reports of small series of
patients, but it is relatively scant on large prospective
studies with regard to outcomes or specific interventions. A large body of case reports detail rare conditions that are difficult to effectively study. As a result,
much of the evidence that exists must be interpreted
in the light of expert opinion, considering the potential hazards while keeping in mind that such complications are relatively rare but cannot be missed.
Several sets of guidelines exist in the current literature; however, even these are primarily grounded
in expert consensus and class III evidence, rather
than well-designed studies. The American College of
Obstetrics and Gynecology (ACOG) has published
guidelines regarding the care of obstetric trauma
patients that were last updated in 19982 (replacing
Number 151, January 1991 and Number 161, November 1991). ACOG issued separate guidelines for
administration of anti-Rh antibodies that specifically
addressed trauma patients (last updated in 1999)3
and guidelines regarding appropriate diagnostic imaging (last updated in 2004).4 In September 2004, the
American College of Emergency Physicians (ACEP)
www.ebmedicine.net • April 2013
released guidelines on administration of Rh immune
globulin to trauma patients in their first trimester as
part of their first-trimester vaginal bleeding review,5
which mirrors ACOG guidelines. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines regarding the surgical approach
to trauma patients as recently as 2010.6 Likewise,
Advanced Trauma Life Support® (ATLS®) general
guidelines also exist for the surgical management
of obstetric trauma. All of these guidelines were
reviewed for this issue. To the authors’ knowledge,
there is no current set of guidelines endorsed by any
emergency medicine association that specifically
addresses the resuscitation and care of the obstetric
patient in the emergency department (ED).
disturbing trend is that while severe injuries on presentation predict poor outcomes for mother and neonate,16-18 even minor trauma to the mother can result
in seriously adverse perinatal outcomes. A pregnant
trauma victim should raise heightened suspicion of
occult injury and requires longer monitoring.
Pathophysiology
Pregnancy is typically divided into 3 trimesters.
Weeks 1 through 13 mark the first trimester; weeks
14 through 26 comprise the second trimester; and
weeks 27 through 40+ comprise the third trimester.
During the course of pregnancy, a woman’s physiology changes dramatically. The major changes are
summarized in Table 1.
Epidemiology And Outcomes
Table 1. Overview Of The Physiological
Changes Of Pregnancy
While modern medicine has made great strides in reducing maternal peripartum morbidity and mortality,
humans routinely take great risks in their daily lives.
The biggest risk for maternal death during pregnancy
continues to be trauma, with motor vehicle accidents
accounting for nearly half of all obstetric traumas
in the United States, followed by falls and assaults.7
Major trauma is estimated to complicate between 3%
and 8% of pregnancies in the United States.8-10 One
retrospective analysis of 16,092 pregnant patients
hospitalized in 2007 reported that 38% resulted in a
delivery.11 In a retrospective study in California of
10,316 deliveries due to a traumatic mechanism, the
overwhelming majority were admitted with blunt
trauma.7 Another retrospective analysis in Baltimore,
MD revealed that, of the 3976 patients arriving for
Level I trauma during a 4-year period, around 3%
were pregnant, and 8% of those pregnant traumas
were newly diagnosed.12 Trauma to pregnant patients
is not rare, and while overwhelming complications
may seldom be seen, most emergency clinicians will
eventually encounter a pregnant patient with trauma
who requires lifesaving interventions.
In 1990, one of the few prospective analyses
of outcomes after trauma definitively showed that
serious complications (such as abruption or premature delivery) occurred in a significant number
of patients with only mild or moderate injuries.13
This was further substantiated by a retrospective
review of pregnant trauma patients in the state of
Washington that showed that injury severity scores
were poor predictors of adverse outcomes and that
even minor injuries could result in fetal demise.14
Other efforts to determine predictors of adverse
fetal outcomes have produced variable findings, but
few have found any predictors that can be reliably
utilized to make determinations without a minimum of 6 hours of maternal and fetal monitoring.15
Trauma during pregnancy has negative effects on
both maternal and newborn morbidity, but the most
April 2013 • www.ebmedicine.net
Physiology
Clinical Significance
Cardiovascular
• Diminished arterial blood
pressure during second
trimester
• Increased cardiac output
• Increased circulating volume
• Supine hypotensive syndrome
• Relatively higher blood losses
may be difficult to detect
• Patients should be transported in left lateral decubitus
position
Hematologic
• Relative anemia (second and
third trimester)
• Leukocytosis
• Diminished platelets
• Elevated fibrinogen, normal
coagulation
• Relative anemia and higher
plasma volume may make
blood losses difficult to detect
Pulmonary
• Elevated diaphragm
• Increased minute ventilation
and tidal volume
• Partially compensated respiratory alkalosis (pCO2 30-40)
• Diminished functional residual
capacity
• Higher chest tubes
• More difficult intubations
Gastrointestinal
• Increased uterine volume
• Displacement of abdominal
contents
• Relatively insensitive abdominal wall
• Delayed gastric emptying
• Diminished gastroesophageal
sphincter tone
• Viable fetus roughly correlates with fundus at the
umbilicus
• Low sensitivity of abdominal
physical examination
• More difficult intubations
Musculoskeletal
• Increased ligamentous laxity
• Lower center of gravity
• Greater back strain
• Higher rate of orthopedic
injuries
Abbreviation: pCO2, partial pressure of carbon dioxide.
3
Emergency Medicine Practice © 2013
Cardiovascular
Overall cardiac output increases during pregnancy.
Resting heart rate increases approximately 10 to 15
beats per minute to accommodate a higher circulatory demand, while resting arterial blood pressure
typically declines during the second trimester and
slowly recovers to baseline near term. Any evidence
of relative hypertension suggests the possibility of
eclampsia. Venous pressure below the diaphragm
tends to increase as the uterus enlarges, and later in
pregnancy, the gravid uterus can cause mechanical
obstruction to venous return when the patient is in
the supine position, a condition known as the “supine hypotensive syndrome.” Because some women
with this syndrome are prone to dramatic decreases
in cardiac output, pregnant patients should be transported in the left lateral decubitus position whenever possible, or with pillows propping a spine board
toward the left to minimize supine hypotension.
Hematologic
Pregnancy induces increases in total plasma volume and erythrocyte production that progress
over the course of the pregnancy; however, in the
third trimester, erythrocyte production falls behind
plasma production, commonly resulting in a relative
anemia. Leukocyte counts can be slightly elevated
(although these are postulated to be somewhat ineffective due to hormonal alterations); thus, pregnant
women are thought to be more prone to infectious
disease despite a slight leukocytosis. Platelets can
decrease slightly as the patient nears full term, and
fibrinogen levels are measurably higher, although
clotting times remain normal. The relative increase
in plasma volume means that a significant volume
of blood can be lost in a pregnant patient prior to
hemodynamic collapse, and pregnant patients with
abnormal vital signs are typically more hypovolemic
than their vital signs would suggest.
Pulmonary
During pregnancy, the increasing abdominal volume
of the uterus causes a relative displacement of the
diaphragm cephalad, often resulting in a dyspnea
of pregnancy that causes a partially compensated
respiratory alkalosis and tachypnea with increased
minute ventilation and tidal volumes. Thus, partial pressure of carbon dioxide (pCO2) values in
the pregnant patient typically run in the range of
30 to 40, and functional residual capacity is diminished, resulting in an overall diminished respiratory
reserve that can also worsen in the supine position.
Consequently, normal respiratory values should
alert the emergency clinician to respiratory compromise. The diminished respiratory reserve combined
with underlying hypoventilation means that pregnancy makes for more difficult airways. The elevation of the diaphragm means that patients require
Emergency Medicine Practice © 20134
higher chest tube placement to avoid entrance of the
chest tube into the abdominal cavity. Typically, this
requires that chest tubes be placed 1 to 2 intercostal
spaces higher, in the third or fourth intercostal area.
Gastrointestinal
The enlarging uterus results in displacement of the
majority of the gastrointestinal tract further superior
in the abdomen, resulting in a higher incidence of
bowel injuries with relatively superior abdominal
trauma. Prior to the second trimester, the uterus is
relatively low in the pelvis, resulting in a low rate of
intrauterine injury. Late in pregnancy, the displacement of abdominal contents by the uterus as well
as stretching of both the abdominal musculature
and peritoneum makes the abdominal examination
unreliable for diagnosis of intra-abdominal injury.
Consequently, a benign abdominal examination does
not rule out abdominal injury. Both mechanical and
hormonal alterations result in a relaxed gastroesophageal sphincter with subsequent reflux and delayed
gastric emptying, again setting up for a potential
airway disaster should intubation be required.
Musculoskeletal
Hormonal alterations during pregnancy result in
gradual laxity of the ligaments, which can lead to orthopedic injuries, particularly in the pelvis. Furthermore, the gravid uterus results in a lower center of
gravity and exaggeration of kyphosis and lordosis,
which can predispose the patient to back injuries.
Differential Diagnosis
While the majority of minor trauma in pregnant patients appears straightforward, even minor injuries
can result in severe morbidity to the fetus. Consequently, the emergency clinician should be cognizant
of several potential life threats to both mother and
fetus, including placental abruption, which has been
shown to occur in even relatively minor trauma.19-21
(See Table 2.) Sheer forces to an elastic uterus with
the relatively inelastic placenta sensitizes the mother
to blunt force trauma (eg, placental abruption).22
Uterine rupture is a less common but a much more
significant life threat to the mother that can occur
when the uterine wall is torn, resulting in intraperitoneal hemorrhage and placental abruption.23,24
Table 2. Life-Threatening Diagnoses In
Pregnant Trauma Patients
•
•
•
•
•
Placental abruption
Premature labor
Uterine rupture
Amniotic fluid embolism
Maternal-fetal hemorrhage and alloimmunization
www.ebmedicine.net • April 2013
Premature rupture of membranes and subsequent
premature labor can result in significant morbidity
for the fetus and can lead to potential infection.
Amniotic fluid embolism occurs in < 1% of all
normal deliveries, but it has a fatality rate approaching 30%.25 Amniotic fluid embolus may present
similarly to a pulmonary embolus, with extreme cardiovascular collapse and hypoxia, and it necessitates
immediate resuscitation. Additionally, exposure to
fetal blood during trauma can result in Rh alloimmunization in Rh-negative mothers. While this is not
an immediate life threat to the mother, it is essential
to treat it in order to avoid significant problems with
future pregnancies.
for life-threatening injuries that would be better
addressed by the emergency and trauma teams. Ideally, any advance notification of an obstetric trauma
patient with potential injuries should prompt notification of both the trauma surgeon and obstetrician
in order to provide coordinated care. In the absence
of any major trauma or pain, it may be appropriate
to send the patient to labor and delivery after a primary and secondary survey is performed. The initial
assessment focuses primarily on the mother.
History
History taking should include a brief pregnancy
history. The emergency clinician should be aware
that any female trauma patient of childbearing age
may be pregnant. Therefore, every female trauma
patient should be asked about pregnancy, and a
pregnancy test obtained as soon as possible. Most
bedside urine pregnancy tests will work equally
well with a whole blood sample, which may expedite results in a patient who cannot urinate or does
not require urinary catheterization.28 In a patient
who knows she is pregnant, gestational age is useful
in determining the viability of the fetus. While 24
weeks is generally considered the cusp of viability at
most institutions in the United States, in the absence
of definitive knowledge of the gestational age, it is
reasonable to lower the bar to 20 weeks in the case of
a moribund patient who might require a perimortem
cesarean section. Any complaint of abdominal pain
or vaginal bleeding should prompt an immediate
obstetrical consultation for possible intra-abdominal
catastrophe.
Prehospital Care
Transport of the pregnant patient follows the standard prehospital trauma guidelines for rapid assessment and transportation to the nearest appropriate
facility, with a few notable exceptions. Whenever
possible, early estimation of gestational age is useful
to obtain from family members or the patient herself. This is essential to initial assessment, and later
decompensation due to injury may make a reliable
history difficult to ascertain. Due to maternal supine
hypotension syndrome, it is imperative that any patient who is being transported later in her pregnancy
be placed in the left lateral decubitus position or, if
placed in spine precautions, that a pillow be placed
under the right side of the spine board to improve
venous return. When this is not possible, manual
displacement of the uterus to the left may be necessary. Whenever possible, transportation should be
to a center that is able to provide obstetrical care, as
long-term monitoring is usually required for these
patients. Nonetheless, remembering that the best
possible outcome for the fetus is to take care of the
mother, any immediately life-threatening injuries that
may necessitate a perimortem cesarean section should
be addressed at the nearest possible facility. Given
the fragile state of the fetus and its susceptibility to
relative hypotension and hypoxia, the mother should
be placed on supplemental oxygen and intravenous
(IV) crystalloid should be administered for any signs
of hypotension.26 In the event that cardiopulmonary
resuscitation (CPR) is initiated, the patient should be
kept with a wedge under the spine board to improve
venous return; while this may result in less-effective
compression force, it is thought to be adequate. Likewise, if defibrillation is indicated, normal adult doses
are likely to be effective.27
Primary Survey
ATLS® protocols hold true for the primary survey,
as the underlying assumption remains that the best
situation for the fetus is a stable mother; hence, the
primary survey in the pregnant patient focuses on
the mother. Airway and breathing should be immediately addressed, as the fetus is particularly susceptible to hypoxia, and either oxygen administration
or advanced airway management should proceed, if
indicated. Keeping in mind the physiologic changes
in pregnancy, airway management in the pregnant
patient includes a greater risk of aspiration, increased airway edema, diminished functional capacity (and thus quicker desaturations during apnea),
and diminished cardiovascular tone. None of these
factors should delay or hinder airway management,
but they should heighten awareness of the potential
for a difficult airway. Medications used in rapid
sequence intubation (such as succinylcholine) cross
the placenta.29 The effects of succinylcholine on the
fetus have not been associated with adverse events
in the setting of maternal intubation in the anesthesia literature.
Crystalloid is effective in improving neonatal
oxygenation if there is evidence of maternal hypo-
Emergency Department Evaluation
Upon arrival at the hospital, pregnant trauma
patients should be evaluated in the ED first, prior
to transport to labor and delivery, in order to assess
April 2013 • www.ebmedicine.net
5
Emergency Medicine Practice © 2013
tension,26 but if hypotension is suspected to be due
to hemorrhage, O-negative blood is the resuscitation fluid of choice. Little definitive research exists
in regard to vasopressor choice in the hypotensive
pregnant patient, but any thought of vasopressors in
a pregnant trauma patient should first prompt consideration of hemorrhage and then an evaluation for
any other underlying cause of hypotension to guide
vasopressor choice.
Secondary Survey
As the secondary survey proceeds to assess all
potential maternal injuries, attention should also be
paid to the second other patient in the trauma, the
fetus. Gestational age can be estimated by fundal
height with the patient in the supine position. A
fundus at the height of the umbilicus is equivalent
to approximately 20 weeks’ gestation. (See Figure
1.) Given the potential for several weeks’ error with
this method and the possibility of a viable fetus
at around 24 weeks, any pregnant woman with a
fundus at the umbilicus should be considered to be
carrying a viable fetus. In third-trimester pregnancies, vaginal speculum examination is generally
avoided due to risk of infection and bleeding, but
if there is vaginal bleeding, it may be necessary
to determine the source. As soon as possible, fetal
cardiotocographic monitoring should be initiated to
determine the well-being of the fetus. In the absence
of immediate fetal cardiotocographic monitoring,
fetal heart rate via Doppler or bedside ultrasound is
recommended to assure that the fetus is viable, with
normal heart rates being between 120 and 160 beats
per minute.
is no compelling evidence regarding who should
receive anti-Rho antibodies, all Rh-negative women
in their second or third trimester who experience
abdominal trauma should be given a standard dose
of Rho(D) immune globulin, usually 300 mcg.3 It is
suggested that further screening be undertaken to
evaluate for massive fetal-maternal hemorrhage,
as a standard dose of Rho(D) immune globulin is
capable of protecting only up to 30 mL of fetal blood
exposure. Measurement of fetal blood exposure is
accomplished via quantitative analysis on a maternal blood sample via the Kleihauer-Betke (KB)
acid elution test, which detects fetal red blood cells
in maternal blood. It can be used to quantify the
estimated volume of fetal-maternal hemorrhage and
guide further Rho(D) immune globulin administration. Positive KB testing is associated with higher
rates of preterm labor, even in Rh-positive mothers,30
and studies show that larger hemorrhages may occur more often than previously thought.31 However,
Rho(D) immune globulin is effective in preventing
alloimmunization within the first 72 hours, which
means that this is largely not a problem with which
the emergency clinician needs to be concerned. The
ACEP clinical policy on first-trimester bleeding includes a C-level recommendation that first-trimester
Figure 1. Fundal Height And Estimated
Gestational Age
Diagnostic Studies
Laboratory Abnormalities
Physiologic anemia of pregnancy results in decreased maternal hemoglobin during later phases
of pregnancy, due in part to an increased circulating
plasma volume. Because white blood cells can be
mildly elevated due to pregnancy and are frequently
elevated in the setting of trauma, the test is an
unreliable indicator of infection. Circulating clotting
factors may be increased throughout pregnancy, rendering the qualitative D-dimer a useless screening
tool for pulmonary embolus in pregnancy.
Kleihauer-Betke Testing
Detection of fetal-maternal hemorrhage is imperative to prevent maternal alloimmunization in Rhnegative mothers. A type and screen should be sent
immediately upon the patient’s arrival to determine
maternal Rh status. Rh-negative patients should be
considered for anti-Rho antibodies (Rho(D) immune
globulin) if there is concern for bleeding or abruption. ACOG guidelines suggest that while there
Emergency Medicine Practice © 20136
Tintinalli J, Stapcyznski JS, Ma OJ, Cline DM, Cyduka RK, Meckler GD. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 7th Edition, http://www.accessmedicine.com. Copyright © The
McGraw-Hill Companies, Inc. Used with permission.
www.ebmedicine.net • April 2013
trauma victims who are Rh-negative receive a dose
of Rho(D) immune globulin to prevent alloimmunization.5 Therefore, any significant abdominal
trauma in an Rh-negative woman should prompt
both immediate administration of Rho(D) immune
globulin as well as KB testing to be followed up by
the obstetric team.
be deferred to the inpatient obstetrical team, where
such long-term monitoring is likely to occur.
Imaging
Ultrasound
Ultrasound is the preferred imaging modality in
pregnant women as it avoids the risk of radiation to
the fetus and is readily and rapidly available in most
settings. The focused assessment with sonography
for trauma (FAST) examination is commonly used in
both pregnant and nonpregnant trauma patients. A
large retrospective review of the FAST examination
to detect free fluid in pregnant trauma patients
found a reasonable specificity and accuracy (> 90%)
but, not surprisingly, a rather low sensitivity (61%),
demonstrating that the FAST examination remains
a reasonable screening tool for intraperitoneal
hemorrhage but that it does not rule out intraabdominal pathology.33 (See Figures 5-7, page 8.)
The same study showed that the FAST examination
was more sensitive in nonpregnant women than in
pregnant women,33 although a smaller retrospective
study showed similar sensitivities in pregnant and
Fetal Cardiac Monitoring
Electronic fetal monitoring, also known as cardiotocography, is widely used during routine labor and
delivery in the United States as well as during any
time the pregnant patient and her fetus require close
monitoring. While still the subject of much debate
regarding its utility and consequences in normal
labor and delivery, electronic fetal monitoring is the
best indicator of fetal distress, and it is typically the
only measurement available for a trauma patient.
Fetal distress following trauma can be an early indicator of placental abruption, potentially allowing
for earlier intervention. Signs of fetal distress include
fetal bradycardia (fetal heart rate < 120 beats/min),
fetal tachycardia (fetal heart rate > 160 beats/min),
absent heart rate variability, or late or prolonged
decelerations.32 (See Figures 2-4 for examples.) Any
evidence of fetal distress should prompt immediate
notification of the obstetric team, as delivery may
be indicated and should be performed in a more
controlled environment, if possible. Monitoring of
contractions is also useful (as the absence of contractions is generally a reassuring indicator), and studies point towards the absence of contractions and
reassuring fetal cardiac activity after 4 to 6 hours as
being appropriate indicators for release to home.15
At most institutions, fetal cardiac monitoring should
Figure 3. Fetal Heart Rate Tracing
Demonstrating Late Decelerations
Fetal heart rate is on the top; contractions are on the bottom. Time
is on the x-axis. With the first and third contractions, the fetal heart
rate drops toward the end of the contraction. Late decelerations can
indicate fetal hypoxia.
Figure 2. Fetal Heart Rate Tracing
Demonstrating Prolonged Deceleration
Figure 4. Fetal Heart Rate Tracing
Demonstrating Variable Decelerations
Fetal heart rate is on the top; contractions are on the bottom. Time is
on the x-axis. In the latter portion of the tracing, the fetal heart rate
drops below 100 beats/min and stays there for a prolonged period
of time following a contraction. Prolonged decelerations can indicate
fetal distress.
Figures 2, 3, and 4 are reprinted from Clinics in Perinatology, Vol. 38,
issue 1, Molly J. Stout and Alison G. Cahill, “Electronic Fetal Monitoring: Past, Present, and Future,” pages 127-142, Copyright 2011, with
permission from Elsevier.
April 2013 • www.ebmedicine.net
Fetal heart rate is on the top; contractions are on the bottom. Time
is on the x-axis. Maternal heart rate is in the middle. Decelerations
occur at varying times in relation to the contractions. Variable decelerations can indicate cord compression. In this tracing, the mother
appears to be pushing, as evidenced by the multiple peaks within
each contraction.
7
Emergency Medicine Practice © 2013
nonpregnant women.34 Among pregnant women,
the sensitivity of ultrasound for detecting traumatic
injury is highest during the first trimester. Some
experts believe that, in the stable pregnant trauma
patient, computed tomography (CT) scanning is
indicated only if the FAST examination is positive,35
but this remains controversial. A recent retrospective
review study including 176 pregnant trauma
patients found that CT can accurately diagnose
placental abruption, potentially suggesting another
indication for CT even in the presence of a negative
FAST examination.36 Another benefit of sonography
during initial resuscitation is the potential to
identify pregnancy in a patient who is either
unaware she is pregnant or unable to communicate
her pregnancy. Bedside ultrasound is also useful
during the initial evaluation to obtain fetal cardiac
activity if it cannot be done via Doppler; however,
it must be stressed that due to the relatively limited
sensitivity of ultrasound, pregnant trauma patients
require at least 4 to 6 hours of observation with
fetal monitoring, even in the presence of a negative
FAST examination. While there is a paucity of data
specifically citing outcomes among patients with a
negative FAST examination, this is considered best
practice at this time.
The decision to expose a pregnant patient to
radiation must carefully balance the risks and benefits to the mother and the fetus. There are multiple
factors involved in determining the impact of fetal
radiation exposure, including age of gestation, type
of imaging, and body site of exposure. Unfortunately, little prospective data exist on these risks,
as most studies in this area are based on extrapolated studies of nuclear bomb survivors. The risk
of teratogenesis is dose-dependent, and it is considered to be most harmful during weeks 8 to 15 of
Figure 5. Third-Trimester Pregnancy
Ultrasound
Arrow notes the location of the fetal heart, which can be used in Mmode to determine fetal heart rate during the FAST assessment.
Image used courtesy of Rob Ferre, MD.
Emergency Medicine Practice © 20138
pregnancy, when organogenesis occurs. During the
period of organogenesis in a fetus, radiation doses
> 100 to 200 mGy have been associated with fetal
malformations, including microcephaly and other
central nervous system deficits as well as intrauterine growth restriction.37 Consensus statements
from both the American College of Radiology37
and ACOG’s 2004 guideline agree that the risk of
adverse fetal outcomes—including fetal malformations and malignancy—is negligible in fetal radiation doses < 50 mGy (5 rad) when compared with
the risk of background radiation.37 Most routine
imaging studies expose the fetus to < 50 mGy; however, trauma patients often require multiple imaging studies that could increase the dose and exceed
Figure 6. Positive FAST Examination In
Right Upper Quadrant
Arrow points to the thin rim of hypoechoic (dark) fluid in the space
between the liver (L) and kidney (K). Such a stripe is indicative of
free peritoneal fluid, likely hemorrhage.
Image used courtesy of Rob Ferre, MD.
Figure 7. Positive FAST Examination In Left
Upper Quadrant
Arrow points to a thin triangle of fluid just below the superior pole of
the spleen (S) next to the left kidney (K), indicating fluid in the perisplenic space, likely hemorrhage.
Image used courtesy of Rob Ferre, MD.
www.ebmedicine.net • April 2013
the 50 mGy cutoff. (See Tables 3 and 4 for samples
of radiation doses from common examinations.)
The emergency clinician should proceed with standard trauma management utilizing the principle of
“as low as reasonably achievable” (ALARA) radiation exposure, without compromising patient care.
At no point should a diagnostic study that might
significantly impact the welfare of the mother be
delayed due to fear of fetal radiation exposure, as
there is marked risk to the fetus if the mother has
life-threatening injuries that go unrecognized without imaging. In a retrospective study by Richards
et al, 328 pregnant trauma patients were identified,
23 of whom had intra-abdominal injury. Of those, 9
had false-negative ultrasounds when compared to
the gold standard of CT and/or operative intervention.33 Therefore, the consensus is that radiological
evaluation should proceed for blunt and penetrating trauma as with other major trauma, with an
emphasis on ordering only pertinent studies.
The carcinogenic effect of radiation on a fetus
is less clearly delineated than that of teratogenesis.
Some studies have demonstrated a correlation
between in utero radiation exposure and childhood malignancies. Studies suggest that this risk of
carcinogenesis may be greater when exposure occurs
during the first trimester as opposed to later in pregnancy. One helpful statistic to use in conversations
with patients about this risk is that radiation doses
> 100 mGy may result in an increased risk of 1%
for the combination of teratogenic effects and later
development of childhood cancer.37
Iodinated contrast agents are known to cross
the placenta and pose theoretical risk to the fetal
thyroid, but no known case reports exist of adverse
outcomes from the use of CT contrast agents in pregnancy; thus, recommendations are that they be used
with caution.37 Risks and benefits of imaging must
be weighed individually in each case of a pregnant
trauma patient.
Table 3. Estimated Conceptus Doses
From Radiographic And Fluoroscopic
Examinations
Typical Conceptus
Dose (mGy)
Cervical spine (AP, lateral)
< 0.001
Extremities
< 0.001
Chest (PA, lateral)
0.002
Thoracic spine (AP, lateral)
0.003
Abdomen (AP)
• 21-cm patient thickness
• 33-cm patient thickness
1
3
Lumbar spine (AP, lateral)
1
Limited intravenous pyelogram*
6
Small-bowel study†
7
Double-contrast barium enema study
‡
7
Abbreviations: AP, anteroposterior projection; mGy, milligray; PA,
posteroanterior projection.
*Limited intravenous pyelogram is assumed to include 4 abdominopelvic images. A patient thickness of 21 cm is assumed.
†
A small-bowel study is assumed to include a 6-min fluoroscopic
examination with the acquisition of 20 digital spot images.
‡
A double-contrast barium enema study is assumed to include a 4-min
fluoroscopic examination with the acquisition of 12 digital spot images.
Table 4. Estimated Conceptus Doses From
Single Computed Tomographic Acquisition
Examination
Dose Level
Typical
Conceptus
Dose (mGy)
Extraabdominal
• Head CT
• Chest CT
Routine
Pulmonary embolus
Standard
Standard
Standard
Standard
0
0
0.2
0.2
Standard
0.1
Standard
Standard
4
25
CT angiography of aorta (chest
through pelvis)
Standard
34
Abdomen/pelvis, stone protocol*
Reduced
10
l
l
CT angiography of coronary
arteries
Magnetic Resonance Imaging
The use of magnetic resonance imaging (MRI) in
pregnant patients is highly recommended due to
the lack of any known risk to the fetus in utero;4,37
however, gadolinium and related contrast agents
have theoretical teratogenic and abortive effects that
contraindicate their routine use. While MRI would
provide a reasonable way to safely image pregnant
blunt trauma patients, its limited availability at most
centers combined with its relatively long sequence
time to obtain images limits its usefulness as an
imaging modality in seriously ill pregnant patients.
In the nonacute patient, however, MRI is an excellent
imaging modality for evaluation of both intraabdominal and intrathoracic complaints, as well as
musculoskeletal injuries, when it is available.
April 2013 • www.ebmedicine.net
Examination
Abdominal
• Abdomen, routine
• Abdomen/pelvis, routine
Abbreviations: CT, computed tomography; mGy, milligray.
*Anatomic coverage is the same as for routine abdominopelvic CT,
but the tube current is decreased and the pitch is increased because
standard image quality is not necessary for detection of high-contrast
stones.
Tables 3 and 4 are reprinted from McCullough CH, Scheuler BA,
Atwell TD, et al. Radiation exposure and pregnancy: when should we
be concerned? RadioGraphics. 2007;27-909-917. Used with permission of Radiological Society of North America.
9
Emergency Medicine Practice © 2013
Clinical Pathway For Management Of Pregnant Trauma Patients
Primary survey and assessment:
• Airway
• Breathing
• Circulation
• Address maternal injuries
• Administer Rho(D) immune
globulin to Rh-negative
patients (Class II)
• No further fetal monitoring
necessary
< 24 WEEKS
Secondary survey:
• Determine gestational age
• Perform ultrasound for fetal
viability
• Type and screen for Rh
status (Class III)
UNSTABLE
UNSTABLE
> 24 WEEKS
•
•
•
•
•
Initiate continuous electronic fetal monitoring
Address maternal injuries
Administer Rho(D) immune globulin to Rh-negative patients (Class III)
Send KB testing for possible massive fetal-maternal hemorrhage
Image per trauma protocol with attempts to keep doses as low as possible
(Class III)
• Screen for domestic violence (Class II)
Resuscitation:
• Administer oxygen (Class II)
• Consider advanced airway
• Left lateral decubitus positioning/
wedge under spine board (Class III)
• Administer IV crystalloid (Class II)
• Consider blood transfusion
LOSS OF VITAL SIGNS
UNSTABLE
Perform perimortem cesarean section
within 4 min if estimated gestational
age > 24 wk (Class III)
STABLE
Minimum 4-6 h of
continuous electronic
fetal monitoring prior to
discharge consideration
(Class II)
NONE PRESENT
Continuous electronic fetal monitoring shows:
• Late or persistent decelerations
• Contractions
or
• Severe abdominal pain
• Rupture of membranes
• Vaginal bleeding
(All are Class III)
ANY PRESENT
Immediate obstetric consultation
and admission for intervention
or 24-h monitoring (Class III)
Abbreviations: IV, intravenous; KB, Kleihauer-Betke testing.
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and
effectiveness
Level of Evidence:
• One or more large prospective
studies are present (with rare
exceptions)
• High-quality meta-analyses
• Study results consistently positive and compelling
Class II
• Safe, acceptable
• Probably useful
Level of Evidence:
• Generally higher levels of
evidence
• Nonrandomized or retrospective
studies: historic, cohort, or case
control studies
• Less robust randomized controlled trials
• Results consistently positive
Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments
Level of Evidence:
• Generally lower or intermediate
levels of evidence
• Case series, animal studies, consensus panels
• Occasionally positive results
Indeterminate
• Continuing area of research
• No recommendations until
further research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American
Heart Association and represen-
tatives from the resuscitation
councils of ILCOR: How to Develop Evidence-Based Guidelines
for Emergency Cardiac Care:
Quality of Evidence and Classes
of Recommendations; also:
Anonymous. Guidelines for cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee
and Subcommittees, American
Heart Association. Part IX. Ensuring effectiveness of communitywide emergency cardiac care.
JAMA. 1992;268(16):2289-2295.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2013 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
Emergency Medicine Practice © 201310
www.ebmedicine.net • April 2013
for acute carbon monoxide exposure concluded that
hyperbaric oxygen is safe in pregnant women,40 although definitive benefit in trauma patients has not
been established, and hyperbaric treatment may be
contraindicated due to the need for other treatments
that may not be feasible in a hyperbaric chamber.
Hydroxocobalamin is approved by the United
States Food and Drug Administration for use in
pregnant women when cyanide exposure is suspected. The initial dose in adults is 5 g administered intravenously over a 15-minute period. A
second dose of 5 g may subsequently be administered.38 An important difference between this
treatment and the previously used cyanide antidote
kit is that the latter forms methemoglobin, which is
potentially toxic to a fetus. Hydroxocobalamin does
cross the placenta, so it, theoretically, directly treats
the fetus as well as the mother.
Based on the best available evidence, pregnant
trauma patients suspected of having significant
inhalational injury should be provided 100% oxygen
via a nonrebreather face mask and should be administered hydroxocobalamin. Following the initiation
of these interventions, other treatments may be
considered, including hyperbaric oxygen therapy or
even delivery of the fetus.
Treatment
The Clinical Pathway provides an initial algorithm
for the management of trauma in the pregnant
patient in the ED. Primary and secondary surveys
should be performed to stabilize the mother and
assess the fetus, with unstable maternal physiology
addressed immediately to preserve the life of both
the mother and the fetus. Basic measures to optimize
maternal oxygen delivery, correct positioning with
the uterus displaced to the left, and maintain maternal blood pressure should be undertaken to assure
optimum fetal resuscitation. Cardiotocographic
monitoring should be initiated as soon as possible to
find evidence of either premature labor or fetal distress. Prompt obstetric consultation is recommended
for evidence of either complication. If evidence of
premature labor presents, discussion with obstetrics
should include the indications for administering
steroids for fetal lung immaturity (betamethasone 12
mg intramuscular [IM] or dexamethasone 6 mg IM)
and tocolytics. All Rh-negative mothers should be
administered a single dose of Rho(D) immune globulin, and KB testing should be performed to look for
evidence of large fetal-maternal hemorrhage. Any
patient beyond 24 weeks’ gestation (ie, with a viable
fetus) should be monitored for a minimum of 4 to 6
hours with cardiotocographic monitoring prior to
consideration for discharge, even if there is no obvious injury.
Isolated Orthopedic Injuries
Several small studies of orthopedic injuries in pregnancy suggest that these patients (both with major
and minor orthopedic injuries) have significantly
higher rates of adverse obstetrical outcomes, including placental abruption, preterm birth, and low birth
weight41 as well as delayed complications including
cesarean delivery, fetal death, and neonatal death.42
It is suggested that patients with even minor orthopedic injuries who are pregnant with a viable fetus
should be considered for transfer to a tertiary care
center following stabilization, given the increased
risk of adverse outcomes.42 Major injuries are of
even greater concern, with pelvic fractures (given
the proximity to the uterus) having the highest risk
of adverse obstetrical outcome among orthopedic
injuries.41 In 1 observational study, fetal demise occurred in approximately 30% of pregnant women
with pelvic fractures.42
Unfortunately, even minor orthopedic injuries
that do not require operative repair are correlated
with an increase in adverse pregnancy outcomes.
A suggested explanation for this correlation is that
even single-extremity fractures are often due to
high-energy mechanisms (such as motor vehicle collisions) that bode poorly for fetal outcomes.42 Thus,
it is not the injury itself but the mechanism of injury
with the resultant possibility of other severe injuries
to fetus or mother that should prompt consideration
of transfer to a tertiary care center. Furthermore,
pregnant women with orthopedic injuries who do
Special Circumstances
Carbon Monoxide And Cyanide Poisoning
Smoke inhalation can be harmful to the fetus, particularly when it occurs in combination with trauma.
Carbon monoxide binds to hemoglobin and myoglobin, inhibiting the transport of oxygen. It passes
through the placenta, and carbon monoxide levels
in the circulation can ultimately be 15% higher in
the fetus than in the mother.38 The initial treatment
of suspected carbon monoxide poisoning is 100%
oxygen, which decreases the half-life of carboxyhemoglobin from approximately 5 hours to 1 hour.
Hyperbaric oxygen therapy should also be a strong
consideration, when it is available. While some
experts consider pregnancy to be an indication for
hyperbaric treatment in carbon monoxide poisoning,
no robust guidelines exist in equivocal cases. ACEP’s
clinical policy on carbon monoxide poisoning has
no specific recommendations regarding treatment in
pregnant women, as no randomized controlled trials
exist.39 Although strong evidence does not exist,
the authors recommend discussion with hyperbaric
specialists, as potentially strong (albeit unproven)
benefits may exist for pregnant women. A 1991
randomized controlled trial that followed obstetric
and fetal outcomes of 44 pregnant women treated
April 2013 • www.ebmedicine.net
11
Emergency Medicine Practice © 2013
not have immediate complications while hospitalized continue to have increased obstetrical morbidity after hospital discharge. A subsection of 1
retrospective cohort study involving 2191 patients
noted that the hypercoagulability of pregnancy may
contribute to a 9-fold increase in thrombotic events
among pregnant patients with orthopedic injuries.41
No injury is too small to prompt observation and
follow-up with an obstetrician.
Domestic Violence
Domestic violence results in more deaths each year
than any given medical complication of pregnancy.
Annually, up to 335,000 pregnant patients in the
United States are affected by domestic violence.21 One
in 6 pregnant adult women and 1 in 5 pregnant teenage women are abused, either physically or sexually,
during pregnancy.43 Assault rates are higher in young
women aged < 20 years, African American women,
and multiparous women with > 3 pregnancies. Perinatal complications occur at significantly higher rates
among pregnant women who are victims of assault,
including preterm labor, uterine rupture, premature
rupture of membranes, placental abruption,44 maternal death, and fetal demise.21 These outcomes have
also been found to be intricately intertwined with the
same socioeconomic factors that predispose to domestic violence. Abused women have double the rate
of delayed entry into prenatal care.43,45 Thus, an ED
visit may be a pregnant woman’s first healthcare visit
during her pregnancy, so it is worthwhile for all clinically stable pregnant women to undergo screening
in the ED for domestic violence. It is imperative that
this occur in a private setting, alone with the female,
without her partner present.45
Trauma Prevention (Seat Belts And Airbags)
While approximately 90,000 pregnant women are
injured in motor vehicle collisions each year in the
United States, the majority of women in 1 study denied being counseled about seat belt use during their
prenatal visits.46 Women who are ≥ 30 years of age or
those who have more than a high school education
have the highest rate of self-reported seat belt use.46
Appropriate maternal use of seat belt restraint has
a significantly positive impact on fetal outcomes in
low-impact motor vehicle collisions (which comprise
the majority of car accidents). Fetal outcomes in
high-impact accidents, however, are less dependent
on seat belt use. Use of a 3-point-restraint seat belt
is safer than a shoulder belt alone,47 and inappropriate seat belt use has been shown to result in a higher
rate of poor obstetric and fetal outcomes. One study
noted that half of fetal losses in motor vehicle collisions could be prevented if all pregnant women
wore seat belts correctly and consistently.48 Another
retrospective review noted that pregnant women in
motor vehicle collisions who were not wearing seat
Emergency Medicine Practice © 201312
belts were 2.8 times more likely to experience a fetal
death than pregnant women in motor vehicle collisions who were appropriately belted.8
While seat belt use has strong evidence to
support positive impact on outcomes in pregnant
patients, case studies raise concern that the force of
a deployed airbag may result in fetal injury.49 Few
studies exploring this theory have been published,
and there is no clear evidence that airbag use in
pregnancy results in higher rates of placental abruption or other fetal risks.50 In fact, 1 retrospective
cohort study that included 3348 pregnant women
in motor vehicle collisions found no significant
difference in the risk of adverse outcomes in accidents with airbag deployment as compared to those
without deployment.51 At this time, the general
practice of practitioners advising pregnant women
about preventive care is that seat belts and airbags
should be used consistently and correctly in pregnant women, just as in the general population. For
a pregnant woman, this means keeping the lap belt
low, on the pelvic bones, and placing the shoulder
strap between the breasts. (See Figure 8.) Emergency clinicians may provide a useful public health
benefit by providing seat belt counseling to pregnant
trauma patients in order to prevent future injuries.
Amniotic Fluid Embolism
Amniotic fluid embolism is a rare, but recognized,
complication of pregnancy that is thought to occur
when amniotic fluid enters the mother’s circulation. The incidence is thought to be between 1 in
Figure 8. The Correct Way To Wear A Seat
Belt When Pregnant
Reprinted with permission from the Saskatchewan Prevention Institute.
www.ebmedicine.net • April 2013
Risk Management Pitfalls For Pregnant Trauma Patients
1. “She told me she wasn’t pregnant.”
Incidental finding of pregnancy occurs, and it
can happen to your trauma patient as well. Any
female of reproductive age involved in trauma
should have a screening pregnancy test sent as
part of the initial workup.
6. “She was worried about radiation risks, so we
didn’t do the imaging studies I would have
normally done.”
The relative risk of radiation for most routine
ED x-rays and CT scans is well below the
recommended threshold of radiation exposure
during pregnancy and shouldn’t inhibit a
thorough workup for trauma.
2. “She wasn’t complaining of abdominal pain,
so I wasn’t worried about the pregnancy.”
Even relatively minor orthopedic injuries have
been associated with adverse perinatal outcomes
due to occult intrauterine trauma. All pregnant
patients beyond 24 weeks—even those with
relatively minor trauma—should have electronic
fetal monitoring to assess for intrauterine
pathology for a minimum of 4 to 6 hours.
7. “I wanted to give the mother 1 round of CPR
and check for fetal heart activity before doing a
perimortem cesarean section.”
The indication for perimortem cesarean section
is loss of vital signs, and in order to have the
baby out in less than 5 minutes, no delay
should be undertaken before performing this
potentially life-saving maneuver.
3. “She didn’t look like she was that far along, so
I wasn’t worried about the fetus.”
Gestational age can be assessed by fundal
height, bedside ultrasound, or prior medical
records, but it should be assessed and the
emergency clinician should err on the side of
fetal viability, especially with regard to major
resuscitations.
8. “I didn’t ask about domestic violence.”
Domestic violence is more common during
pregnancy and, frequently, a victim’s first
contact with a medical provider is in the ED.
Simple screening questions, asked in a private
setting, can evaluate for further potential
injuries.
4. “I wasn’t worried about bleeding, so I didn’t
order Rho(D) immune globulin.”
Even minor trauma can result in fetal-maternal
hemorrhage and complications in subsequent
pregnancies in Rh-negative mothers. All
pregnant patients with abdominal trauma or
significant mechanism of injury should be
Rh(D) typed and administered empiric Rho(D)
immune globulin if they are Rh-negative.
9. “I figured she was wearing her seat belt.”
The number 1 source of mortality for pregnant
women is motor vehicle trauma. Education
regarding proper lap- and shoulder-belt
placement can prevent life-threatening injuries.
10. “We just laid her down, and she suddenly lost
her vital signs.”
The supine hypotensive syndrome is common
in later pregnancy and can result in syncope and
dramatically reduced cardiac output. It is easily
avoided by keeping the patient in the left-lateral
decubitus position or by tilting the spine board
15° to the left.
5. “She looked fine, so I just discharged her
home.”
The abdominal examination and laboratory
tests can be deceptive, even with minor trauma.
All pregnant trauma patients should have a
minimum of 4 to 6 hours of electronic fetal
monitoring and obstetric follow-up prior to
discharge from the ED.
April 2013 • www.ebmedicine.net
13
Emergency Medicine Practice © 2013
15,000 and 1 in 54,000 pregnancies, and it portends
a relatively grave prognosis, with mortality ranging
from 30% to 86%.52 A small number of case studies have identified patients in whom amniotic fluid
embolism resulted from traumatic injury, and these
have usually occurred in the setting of blunt trauma
from motor vehicle collisions. In 1 small series of 3
patients, despite minimal (if any) external evidence
of trauma, the patients experienced rapid decline in
clinical status following the insult.52 All 3 patients
were identified to be critically ill out of proportion
to their external injuries upon emergency medical
services arrival to the accident scenes. Two of these
patients died within the hour, despite resuscitation,
while the other patient initially survived but ultimately succumbed to complications 3 weeks later. 52
Importantly, disseminated intravascular coagulation
can result from amniotic fluid embolism, which can
worsen traumatic bleeding. While this complication
is rare, it should be considered in the differential
of any unstable patient. Unfortunately, there is no
silver bullet for treating amniotic fluid embolism,
and resuscitation efforts should focus on stabilizing
maternal hemodynamics and providing adequate
oxygenation to the fetus. Innovative treatments for
amniotic fluid that show promise include pulmonary vasodilators, including inhaled nitric oxide,
sildenafil, and prostacyclin. Consider discussion
with a pulmonologist if you feel that these interventions may be indicated.53
Perimortem Cesarean Section
Perimortem cesarean section is indicated when the
fetus is at (or near) the age of viability and the mother loses vital signs. It is likely increasing in incidence
as education regarding the procedure has become
widespread.54 Multiple case reports have shown that
the procedure is often unnecessarily delayed, yet
outcomes are directly linked to timing of the intervention.27,54 Because brain damage begins to occur
after 4 to 5 minutes of hypoxia, perimortem cesarean
section is ideally performed at the 4-minute mark
following onset of maternal cardiac arrest so that
the baby can be delivered by minute 5. Case studies
support the 5-minute standard, which may increase
both fetal (and possibly maternal) survival.55 Viable
infants have been delivered up to 25 minutes after
the onset of maternal cardiac arrest, so the procedure
should generally be attempted even if a period of
time longer than 5 minutes has passed.56
Once the mother is determined to be moribund,
there should be no delay in proceeding with perimortem cesarean. The procedure is shown in Figure
9. In practice, it requires little more than a scalpel
and shears. The initial incision should be midline,
extending from approximately 4 cm inferior to the
xiphoid process down to the pubic symphysis. (See
View A.) The muscles should be dissected through
and the peritoneum entered. (See View B.) A vertical uterine incision should then be made. (See View
C.) If an anterior placenta is present, it should be cut
through, and the infant should then be delivered.
(See View D.) The placenta should be removed
from the uterus following delivery of the infant.
(See View E.) It is important to continue maternal
CPR throughout the procedure and afterwards to
monitor whether the cesarean section (and resultant
relief of the physiologic aortocaval obstruction) will
allow for return of spontaneous maternal circulation. Closure of the uterus, fascia, peritoneum, and
skin should eventually be performed, but this may
be delayed until return of circulation occurs. In fact,
delaying closure may be preferable in order to allow
for view of the uterus, since significant blood loss
can occur from the uterus following perimortem
cesarean section.
Figure 9. Perimortem Cesarean Section (Continued on page 15)
A
B
C
Tintinalli J, Stapcyznski JS, Ma OJ, Cline DM, Cyduka RK, Meckler GD. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th Edition,
http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. Used with permission.
Emergency Medicine Practice © 201314
www.ebmedicine.net • April 2013
Controversies And Cutting Edge
complications from seemingly minor trauma, some
groups advocate for longer monitoring periods to
avoid any possibility of adverse outcomes.
At discharge, patients should be counseled on
reasons to return to the ED, including vaginal bleeding, abdominal pain or contractions, back pain, or
loss of sensation of fetal movement. Patients in the
first trimester of pregnancy should be counseled
that, with normal fetal cardiac activity seen prior
to discharge, the relative risk of adverse outcomes
is relatively minor for the rest of their pregnancy.
Attempts should be made to coordinate follow-up
care with the patient’s obstetrician for repeat evaluation within 2 weeks to make sure that the pregnancy
continues to progress. Injury-prevention education,
including proper use of seat belts during pregnancy,
should be encouraged.
The entire management of pregnant trauma patients
could be considered controversial due to the lack of
hard evidence or large case series regarding treatment and management. MRI has loomed on the
horizon for decades, promising advanced imaging
potential for trauma patients with minimal risk, but
it still lacks widespread availability, and sequence
times are too long to make imaging practical in sick
patients. The perimortem cesarean section is a de
facto standard of care and is taught in most emergency medicine curricula. While it is dreaded, it
does no harm to an already moribund mother and
has the potential to be life-saving. Fetal tococardiographic monitoring remains somewhat controversial
in the obstetric literature during routine labor, but
in the acute-care setting, there is no question that
monitoring for contractions and fetal distress, while
not perfect, is the only monitoring available that can
identify occult abruption or other fetal pathology
that would prompt delivery or other definitive management in the otherwise stable pregnant patient.
Summary
The care of a pregnant patient with trauma requires
a broad understanding of the underlying maternal
physiology that may affect vital signs and laboratory
values and mask underlying pathophysiology. Initial
resuscitation and evaluation focus on the mother, as
maternal well being is the only way to protect the fetus from hypoxia. Once the mother is stabilized, the
fetus can be assessed for evidence of distress, which
is best addressed via prompt obstetric consultation. Workup should include awareness of the risks
of radiation during pregnancy, with adherence to
doing as little harm as possible while still ordering
the definitive studies to evaluate for occult injury,
including radiography and CT scans, where appropriate. When maternal shock turns to cardiac arrest
with a viable fetus, perimortem cesarean section is
indicated and may add the benefit of improved maternal outcomes when performed within 5 minutes
Disposition
Pregnant trauma patients with a potentially viable
fetus should be monitored for a minimum of 4 to 6
hours on electronic fetal monitoring to determine
any evidence of premature labor or fetal distress.
Ideally, a pregnant trauma patient is stabilized in the
ED, her life-threatening conditions are addressed,
and then she is admitted to the obstetric unit for further monitoring and observation. In cases where the
mother is monitored in the ED, monitoring should
show no evidence of fetal distress and no evidence
of premature labor throughout the period of observation in order to safely discharge.15 Due to delayed
Figure 9. Perimortem Cesarean Section (Continued from page 14)
D
April 2013 • www.ebmedicine.net
E
15
Emergency Medicine Practice © 2013
Time- And Cost-Effective
Strategies
• Consider obstetric consultation early. Even in
the best of circumstances, a pregnant patient
beyond 24 weeks’ gestation is going to require a
minimum of 4 to 6 hours of monitoring, which
is best done in an area of the hospital where personnel are trained to perform such monitoring
and can deal with complications if monitoring
shows evidence of fetal distress. Odds are that
this is not going to be optimally done in the ED.
Get your obstetrician on board early, do your
workup for trauma, and then get the patient to
an area where she can be better assessed and
you can move on to caring for other patients.
• Domestic violence screening can be best carried out during initial triage by the nursing
staff. During triage, it is usually easier to isolate
the patient and, by making domestic violence
screening questions part of the standard triage
script, you can screen every patient effectively.
Risk management caveat: If there are signs of
domestic violence or abuse, make a concerted
effort to get the details yourself, document
thoroughly, and involve a social worker.
• Every female patient who presents with trauma
should have a pregnancy test. It is cheap, quick,
and informs you of the potential for intrauterine
complications. It also influences treatment choices due to medications that are contraindicated
in pregnancy. Bedside urine pregnancy tests can
be used with whole blood samples to rule out
pregnancy if urine is not available.
• Don’t hesitate to utilize radiography in a pregnant trauma patient. National recommendations
recognize the need for appropriate ionizing
radiation during pregnancy, and most single
imaging studies are well below the recommended dose threshold for the fetus. Education
for the patient about the low risk and efforts to
minimize exposure to ionizing radiation should
be included in the discussion as well as the benefits to the mother and the fetus of a thorough
trauma evaluation.
Risk management caveat: Make sure that any
alternative forms of imaging that might be
available (such as ultrasound or MRI) are
considered, and, whenever feasible, have a
discussion with the patient and obtain consent
for extensive radiographic procedures
Emergency Medicine Practice © 201316
of arrest. A minimum of 4 to 6 hours of monitoring
is required in all pregnant patients beyond 24 weeks,
as even relatively minor injuries can result in dramatic fetal injuries.
Case Conclusions
The first patient you saw who was 30 weeks pregnant
with the ankle injury was immediately assessed, and
fetal heart tones were reassuring. After a brief discussion
regarding the relatively minimal risk of plain films, she
was sent for x-rays of the cervical spine and ankle, which
showed a small avulsion fracture of her lateral malleolus,
for which she was placed in a splint. She was started
on electronic fetal monitoring in the ED, which showed
normal fetal heart rate and no evidence of contractions.
You discussed with the obstetric team having her admitted
to the labor and delivery unit for 6 hours of monitoring,
after which she was discharged home without event.
The second patient, who fell while jogging, was
placed on electronic fetal monitoring, and a FAST exam
was performed. Although the FAST exam was negative,
she had several contractions while downstairs and was admitted to the obstetric unit for further monitoring. While
there, she was found to have evidence of mild abruption. It
was treated with conservative management over the next
few days, and she was eventually released.
The third patient who was involved in the motor
vehicle collision arrived to the ED with a barely palpable
pulse and a fundus that was well above the umbilicus.
Because she was nonresponsive to pain upon arrival, you
placed a wedge under the spine board, which improved her
pulse, but you decided to intubate for airway protection.
This went uneventfully, and you began rapid infusion of
crystalloid and called for O-negative blood. As you performed a FAST exam, you anticipated the worst and had a
knife and chlorhexidine at the bedside “just in case.” With
volume, her vitals improved, and she was stabilized and
placed on electronic fetal monitoring, with some variable
decelerations. In consultation with the surgeons, she was
taken to the CT scanner, where several intra-abdominal
injuries were noted, including a splenic laceration and left
kidney laceration, but no evidence of placental abruption
or uterine trauma was seen. She was taken to the surgical
ICU, where over the next 3 weeks she had a rocky course,
but ultimately she underwent a cesarean section and
delivery of a healthy baby girl.
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
random­ized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study
www.ebmedicine.net • April 2013
will be included in bold type following the ref­
erence, where available. In addition, the most informative references cited in this paper, as determined
by the authors, are noted by an asterisk (*) next to
the number of the reference.
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Hahn SA, Lavonas EJ, Mace SE, et al. Clinical policy: critical
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El-Kady D, Gilbert WM, Anderson J, et al. Trauma during
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(Retrospective cohort study; 10,316 patients)
Hyde LK, Cook LJ, Olson LM, et al. Effect of motor vehicle crashes on adverse fetal outcomes. Obstet Gynecol.
2003;102(2):279-286. (Retrospective cohort study; 322,704
patients)
Brown HL. Trauma in pregnancy. Obstet Gynecol.
2009;114(1):147-160. (Retrospective study; 1567 total patients, 102 pregnant)
Chames MC, Pearlman MD. Trauma during pregnancy:
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Kuo C, Jamieson DJ, McPheeters ML, et al. Injury hospitalizations of pregnant women in the United States, 2002. Am J
Obstet Gynecol. 2007;196(2):e161-e166. (Retrospective cohort
study; 16,982 patients)
Bochicchio GV, Napolitano LM, Haan J, et al. Incidental pregnancy in trauma patients. J Am Coll Surg.
2001;192(5):566-569. (Retrospective study; 3976 total patients)
Pearlman MD, Tintinallli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am
J Obstet Gynecol. 1990;162(6):1502-1507. (Prospective cohort
study; 86 pregnant patients)
Schiff MA, Holt VL. The injury severity score in pregnant
trauma patients: predicting placental abruption and fetal
death. J Trauma. 2002;53(5):946-949. (Retrospective study;
294 patients)
Curet MJ, Schermer CR, Demarest GB, et al. Predictors of
outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours. J Trauma.
2000;49(1):18-24. (Retrospective study; 271 patients)
Trivedi N, Ylagan M, Moore TR, et al. Predicting adverse
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17
outcomes following trauma in pregnancy. J Reprod Med.
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Melamed N, Aviram A, Silver M, et al. Pregnancy course
and outcome following blunt trauma. J Matern Fetal Neonatal
Med. 2012;25(9):1612-1617. (Retrospective cohort study; 411
patients)
Petrone P, Talving P, Browder T, et al. Abdominal injuries in
pregnancy: a 155-month study at two level 1 trauma centers.
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patients)
Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol.
2006;108(4):1005-1016. (Review article)
Cahill AG, Bastek JA, Stamilio DM, et al. Minor trauma in
pregnancy--is the evaluation unwarranted? Am J Obstet Gynecol. 2008;198(2):208 e201-e205. (Prospective cohort study;
317 patients)
El Kady D, Gilbert WM, Xing G, et al. Maternal and neonatal
outcomes of assaults during pregnancy. Obstet Gynecol.
2005;105(2):357-363. (Retrospective population-based study;
2070 patients)
Weed BC, Borazjani A, Patnaik SS, et al. Stress state and
strain rate dependence of the human placenta. Ann Biomed
Eng. 2012;40(10):2255-2265. (Nonclinical study; 11 placentas)
Enakpene CA, Ayinde OA, Omigbodun AO. Incomplete
uterine rupture, following blunt trauma to the abdomen: a
case report. Niger J Clin Pract. 2005;8(1):60-62. (Case report)
Smith K, Deimling DL, Hinckley WR. Transporting the
pregnant patient in shock: case report and review. Air Med J.
2009;28(1):37-39. (Case report)
Kramer MS, Rouleau J, Liu S, et al. Amniotic fluid embolism:
incidence, risk factors, and impact on perinatal outcome.
BJOG. 2012;119(7):874-879. (Retrospective population-based
cohort study; 4,508,462 patients with 292 affected)
Simpson KR, James DC. Efficacy of intrauterine resuscitation
techniques in improving fetal oxygen status during labor.
Obstet Gynecol. 2005;105(6):1362-1368. (Randomized study;
42/51/49 patients in each arm)
Jeejeebhoy FM, Zelop CM, Windrim R, et al. Management of
cardiac arrest in pregnancy: a systematic review. Resuscitation. 2011;82(7):801-809. (Meta-review article)
Fromm C, Likourezos A, Haines L, et al. Substituting whole
blood for urine in a bedside pregnancy test. J Emerg Med.
2012;43(3):478-482.
Abouleish EI, Abboud TK, Bikhazi G, et al. Rapacuronium
for modified rapid sequence induction in elective caesarean
section: neuromuscular blocking effects and safety compared
with succinylcholine, and placental transfer. Br J Anaesth.
1999;83(6):862-867. (Randomized blinded trial; 42 patients)
Muench MV, Baschat AA, Reddy UM, et al. Kleihauer-Betke
testing is important in all cases of maternal trauma. J Trauma.
2004;57(5):1094-1098. (Retrospective study; 166 pregnant
patients)
Salim R, Ben-Shlomo I, Nachum Z, et al. The incidence of
large fetomaternal hemorrhage and the Kleihauer-Betke
test. Obstet Gynecol. 2005;105(5 Pt 1):1039-1044. (Prospective
cohort study; 313 cases and 253 controls)
Stout MJ, Cahill AG. Electronic fetal monitoring: past, present, and future. Clin Perinatol. 2011;38(1):127-142. (Review
article)
Richards JR, Ormsby EL, Romo MV, et al. Blunt abdominal
injury in the pregnant patient: detection with US. Radiology. 2004;233(2):463-470. (Retrospective study; 2319 total
patients, 328 pregnant)
Goodwin H, Holmes JF, Wisner DH. Abdominal ultrasound
examination in pregnant blunt trauma patients. J Trauma.
2001;50(4):689-693. (Retrospective study; 127 patients)
Brown MA, Sirlin CB, Farahmand N, et al. Screening sonography in pregnant patients with blunt abdominal trauma.
J Ultrasound Med. 2005;24(2):175-181. (Retrospective study;
1567 total patients, 102 pregnant)
Emergency Medicine Practice © 2013
36. Kopelman TR, Berardoni NE, Manriquez M, et al. The ability
of computed tomography to diagnose placental abruption in
the trauma patient. J Trauma Acute Care Surg. 2013;74(1):236241. (Retrospective review; 176 patients)
37.* Wang PI, Chong ST, Kielar AZ, et al. Imaging of pregnant
and lactating patients: part 1, evidence-based review and
recommendations. AJR Am J Roentgenol. 2012;198(4):778-784.
(Committee guidelines)
38. Roderique EJ, Gebre-Giorgis AA, Stewart DH, et al. Smoke
inhalation injury in a pregnant patient: a literature review
of the evidence and current best practices in the setting of
a classic case. J Burn Care Res. 2012;33(5):624-633. (Review
article)
39. Wolf SJ, Lavonas EJ, Sloan EP, et al. Clinical policy: critical
issues in the management of adult patients presenting to
the emergency department with acute carbon monoxide
poisoning. Ann Emerg Med. 2008;51(2):138-152. (Committee
guidelines)
40. Elkharrat D, Raphael JC, Korach JM, et al. Acute carbon
monoxide intoxication and hyperbaric oxygen in pregnancy.
Intensive Care Med. 1991;17(5):289-292. (Prospective study; 44
patients)
41. El Kady D, Gilbert WM, Xing G, et al. Association of maternal fractures with adverse perinatal outcomes. Am J Obstet
Gynecol. 2006;195(3):711-716. (Retrospective cohort study;
3292 patients)
42. Cannada LK, Pan P, Casey BM, et al. Pregnancy outcomes
after orthopedic trauma. J Trauma. 2010;69(3):694-698, (Observational study; 1055 total patients, 65 pregnant patients)
43. Greenberg EM, McFarlane J, Watson MG. Vaginal bleeding
and abuse: assessing pregnant women in the emergency department. MCN Am J Matern Child Nurs. 1997;22(4):182-186.
(Cross-sectional survey; 261 patients)
44. Leone JM, Lane SD, Koumans EH, et al. Effects of intimate
partner violence on pregnancy trauma and placental abruption. J Womens Health (Larchmt). 2010;19(8):1501-1509. (Retrospective study; 2873 patients)
45. McFarlane J, Parker B, Soeken K, et al. Assessing for abuse
during pregnancy. Severity and frequency of injuries and
associated entry into prenatal care. JAMA. 1992;267(23):31763178. (Prospective cohort study; 691 patients)
46. Sirin H, Weiss HB, Sauber-Schatz EK, et al. Seat belt use,
counseling and motor-vehicle injury during pregnancy:
results from a multi-state population-based survey. Matern
Child Health J. 2007;11(5):505-510. (Cross-sectional study;
37,081 patients)
47. Klinich KD, Schneider LW, Moore JL, et al. Investigations of
crashes involving pregnant occupants. Annu Proc Assoc Adv
Automot Med. 2000;44:37-55. (Case series; 16 patients)
48. Klinich KD, Flannagan CA, Rupp JD, et al. Fetal outcome
in motor-vehicle crashes: effects of crash characteristics and
maternal restraint. Am J Obstet Gynecol. 2008;198(4):450 e451e459. (Retrospective; 57 patients)
49. Bard MR, Shaikh S, Pestaner J, et al. Direct fetal injury due
to airbag deployment and three-point restraint. J Trauma.
2009;67(4):E98-E101. (Case report)
50. Metz TD, Abbott JT. Uterine trauma in pregnancy after motor vehicle crashes with airbag deployment: a 30-case series.
J Trauma. 2006;61(3):658-661. (Case series; 30 patients)
51. Schiff MA, Mack CD, Kaufman RP, et al. The effect of air
bags on pregnancy outcomes in Washington state: 2002-2005.
Obstet Gynecol. 2010;115(1):85-92. (Retrospective cohort
study; 3348 patients)
52. Ellingsen CL, Eggebo TM, Lexow K. Amniotic fluid
embolism after blunt abdominal trauma. Resuscitation.
2007;75(1):180-183. (Case report)
53. Conde-Agudelo A, Romero R. Amniotic fluid embolism: an
evidence-based review. Am J Obstet Gynecol. 2009;201(5):445
e441-e413.
54. Dijkman A, Huisman CM, Smit M, et al. Cardiac arrest in
Emergency Medicine Practice © 201318
pregnancy: increasing use of perimortem caesarean section
due to emergency skills training? BJOG. 2010;117(3):282-287.
(Retrospective cohort study; 55 patients)
55.* Katz V, Balderston K, DeFreest M. Perimortem cesarean
delivery: were our assumptions correct? Am J Obstet Gynecol.
2005;192(6):1916-1920. (Literature review article; 38 cumulative cases)
56. Katz VL. Perimortem cesarean delivery: its role in maternal
mortality. Semin Perinatol. 2012;36(1):68-72. (Clinical policy)
CME Questions
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1. Most major studies on outcomes after trauma
in pregnant patients have shown:
a. Penetrating trauma is more common than blunt trauma.
b. Serious complications can occur with even minor trauma.
c. Injury severity scores are indicative of neonatal outcomes.
d. Trauma in pregnancy is rare.
2. Which of the following is TRUE of the pregnant female anatomy?
a. Lower location of abdominal organs
b. Increased lung volumes
c. Increasing abdominal sensitivity to painful stimuli
d. Lower center of gravity
3. What causes maternal supine hypotension
syndrome?
a. Increased plasma volume with relative anemia
b. Diminished respiratory drive due to relatively low pCO2
c. Decreased overall cardiac output during late pregnancy
d. Obstruction of venous return due to the gravid uterus on the vena cava
www.ebmedicine.net • April 2013
4. At approximately how many weeks’ gestation
does the uterine fundus lie at the umbilicus?
a. 12 weeks
b. 20 weeks
c. 24 weeks
d. 36 weeks
5. Kleihauer-Betke testing is utilized for:
a. Quantifying the amount of fetal blood in the maternal bloodstream
b. Determining the Rh status of the fetus
c. Determining the Rh status of the mother
d. Quantifying maternal anti-Rh antibodies in the mother
6. Electronic fetal monitoring (fetal cardiotocography) should be initiated:
a. Prior to arrival in the ED
b. Immediately upon arrival in the ED
c. As soon as possible after the mother has been stabilized
d. Only after admission to an obstetric service
7. The recommended maximum fetal ionizing
radiation dose in pregnancy is:
a. 5 mGy (0.5 rad)
b. 25 mGy (2.5 rad)
c. 50 mGy (5 rad)
d. 500 mGy (50 rad)
8. Regarding contrast agents in pregnancy, which
of the following is TRUE?
a. Iodine-based and gadolinium contrast agents are both contraindicated.
b. Iodine-based contrast agents are contraindicated; gadolinium is relatively safe.
c. Iodine-based contrast agents are relatively safe; gadolinium is contraindicated.
d. Iodine-based and gadolinium contrast agents are both relatively safe.
View the full text
of all EM Practice Guidelines
Update articles at no charge at
www.ebmedicine.net/EMPGU.
9. Domestic violence screening performed in the
ED:
a. Is useful because this may be the patient’s first encounter with a healthcare practitioner
b. Should be done in private with every pregnant patient presenting to the ED for trauma
c. Provides potential to prevent further harm to the mother and the fetus
d. All of the above
Did You Know?
• That EM Practice Guidelines Update helps you
improve patient care by summarizing Clinical
Policies & Practice Guidelines relevant to your
practice?
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• That you receive all this absolutely free, simply
by being an Emergency Medicine Practice
subscriber?
Emergency Medicine
Practice Subscribers:
10. What is the proper method for a pregnant
woman to wear a seat belt?
a. Lap belt only, without shoulder restraint
b. Lap belt below the belly with shoulder restraint off to one side
c. Lap belt over belly with shoulder restraint between the breasts
d. Lap belt below the belly with shoulder restraint between the breasts
April 2013 • www.ebmedicine.net
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www.ebmedicine.net • April 2013